Fort Belknap Tribal Housing Authority COVID-19 Emergency Rental Assistance Application

Applicants must submit this Form and supporting documentation for each additional month (or three-month prospective period) that they seek Financial Assistance under the ERA Program.

Do you rent the residence in which you are living? *

Yes

No

If yes, continue filling out the application.

If no, you are not eligible for Emergency Rental Assistance Program.

First Name *

Last Name *

Date * +

Date of Birth * +

Tribal Enrollment Number: *

Last 4 of SSN: *

Gender: *

Race and Ethnicity: *

Street Address *

Address Line 2

City *

State *

Zip Code *

County *

Phone Number *

Email Address *

Current Landlord Name: *

Monthly Rental Amount *

Contact Phone: *

Email

Address of Landlord *

Are you an enrolled member of the Assiniboine or Gros-Ventre Tribe? *

yes

no

If no, are you a Native American enrolled in a federally recognized Tribe? *

yes

no

If yes, attach proof of membership of Tribe

Has anyone in your household been unemployed longer than 90 days? *

yes

no

Household Size (total number of adults and minors in rental unit) *

Emergency Rental Assistance Program Funds will be used for the following activities:

a. Rent (current)-Applicants can apply for rental assistance for current month's rent. Up to $1,000.00 per month

b. Prospective Rent (future rent)-Financial assistance for a period of up to 3 months; must re-certify income eligibility every 3 months.

c. Rental arrears- ERAP assistance can pay for arrears as far back as March 13, 2020

d. Utilities and home energy costs-Current month's utility statement amount

e. Utilities and home energy costs arrears- ERAP assistance can pay for arrears as far back as March 13, 2020

All required documents must be attached in order to be considered for assistance